Consultant delayed seeing terminally ill patient

What happened

Mr N was admitted to the acute hospital after surgery at a specialist hospital to reduce the size of a brain tumour. His consultant saw him three days after he was admitted, because he was admitted over a weekend when the consultant was not there. In the meantime, Mr N's family contacted the palliative care team for help for him. Mr N died in hospital after deteriorating quickly.

In response to Mrs P's complaint about this, the Trust made several factual errors. For instance, it got the date of Mr N's death wrong. It corrected these errors in a further response after Mrs P pointed them out.

What we found

Mr N's consultant should have seen him on the first day he was available, which was the day before he actually did. Had he done so, he would probably have recognised that Mr N needed input from the palliative care team, and this would have meant Mr N's family would not have had to chase this up themselves.

Mr N received adequate nursing care while he was in hospital. Aspects of his overall experience were poor, but this was because of the unexpectedly rapid deterioration in his condition rather than poor care.

The Trust's initial response to Mrs P's complaint was poor as it contained a lot of errors.

However, when she pointed this out to the Trust, it put it right by apologising, explaining how it happened and what it had done to prevent something similar happening again, and by providing a response containing accurate information.

Putting it right

The Trust has acknowledged and apologised for the failing we found and the resulting injustice. It has told Mrs P what it is going to do to learn from the failing we identified and what it will do differently in future to prevent the same thing happening again.